HCG Weight Loss

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Please complete the Medical History Form below. Please be completely accurate with your answers. Your information will be stored on our secure server. One of our physicians or clinical advisers will contact you as soon as possible.

*Required Fields

SECTION 1: Personal information

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First Name:

Middle Name:

Last Name:

Email

Driver License:

ADDRESS

Address 1:

Address 2:

City:

State:

Zip:

PHONE NUMBERS

Home:

Best time to call:

Work:

Best time to call:

Cell:

Best time to call:

OTHER

Occupation:

Have you already contacted Kingsberg Medical?Please provide the name of your Clinical Adviser

SECTION 2: Medical History

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GENERAL

Date of birth:

Weight:

Gender:

Male

Female

Height:

PRIMARY PHYSICIAN INFORMATION

Physicians Name:

Phone:

Date of last physical exam with above physician:

FAMILY HISTORY

Does an immediate family member currently have or ever had any of the following?
If yes, please check below and explain in the provided field:

Cardiovascular disease:

Yes

No

Diabetes, thyroid or other Endocrine Disorder:

Yes

No

Hypertension:

Yes

No

Lipid Disorder:

Yes

No

Prostate cancer:

Yes

No

Other forms of cancer:

Yes

No

Other illnesses:

Yes

No

Explain family health history:

LIFESTYLE INFORMATION

Do you smoke?

Yes

No

How much do you smoke per day?

Do you drink alcohol?

Yes

No

How much do you drink per week?

Do you take over the counter supplements?

Yes

No

List Name and Quantity per day/week.

Do you exercise regularly?

Yes

No

Please describe.

Have you tried to lose weight before?

Yes

No

Please describe.

DIAGNOSED HISTORY OF DISEASE

Do you currently have or ever had any of the following? If yes, please check below and explain in the provided field:

Thyroid, Diabetes or other endocrine disorder including insulin resistance:

Yes

No

Arthritis:

Yes

No

Bursitis:

Yes

No

Rheumatism:

Yes

No

Sports Injury(s):

Yes

No

Other illnesses:

Yes

No

List all the medications you are taking. Please be specific (Name, dosage, etc.). Please Type "NONE" in space below if you do not take any prescription medication.

STEROIDS

Prior history of Steroids or hormones?

Yes

No

Please select:

Test:

Yes

No

Deca:

Yes

No

Winstrol:

Yes

No

HGH:

Yes

No

Thyroid:

Yes

No

Other:

Yes

No

Est:

Yes

No

Premarin:

Yes

No

Proges:

Yes

No

Provera:

Yes

No

Birth Control:

Yes

No

Type/Dose/Frequency:

Last used:

Prior Medical Records / Labs?

Yes

No

Any side affects?

Used estrogen-blocker?

Yes

No

QUESTIONS FOR TREATMENT

Do you currently have or ever had any of the following symptoms? As Kingsberg Medical specializes in hormone replacement therapy, it is important to take a complete history of any physical symptoms which might be related to your hormonal status.
If Yes, please check and explain below:

Do you currently have or ever had any of the following symptoms?
If Yes, please check and explain below:

Increased lack of drive:

Yes

No

Increasing fat deposits around the abdomen and/or thighs:

Yes

No

Increasing mood swings:

Yes

No

Increasing sagging muscles or breasts:

Yes

No

Increasing wrinkles:

Yes

No

Increasingly stressed:

Yes

No

Decreased desire and ability to exercise:

Yes

No

Decreased energy or endurance:

Yes

No

Decreased sense of well-being:

Yes

No

Decreasing memory:

Yes

No

Decreasing muscle strength:

Yes

No

Progressive osteoporosis, decreasing bone mass or stooped posture:

Yes

No

Cold or heat intolerance:

Yes

No

Currently Pregnant:

Yes

No

Depression:

Yes

No

Difficulty sleeping:

Yes

No

Headaches / Migraines:

Yes

No

Hot flashes:

Yes

No

Loss of concentration, sociability, activity:

Yes

No

Loss of interest in sex:

Yes

No

Muscle loss:

Yes

No

Sagging, loose or thin skin:

Yes

No

Sore Muscles, join pain(s) or swelling:

Yes

No

Thinning or loss of hair:

Yes

No

Urogenital atrophy:

Yes

No

Weight loss - Unexplained:

Yes

No

Other:

Yes

No

Please use this space to explain any additional information:

SECTION 3: Signature

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Patient Authorization and Agreement

The undersigned Patient ("Patient") authorizes and instructs Kingsberg Medical ("Kingsberg Medical") to provide the Patient with medical management, administrative and referral services. Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement ("Agreement"). Patient submits with this Agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond truthfully, accurately and completely on the MHF and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to the physicians referred by Kingsberg Medical ("Physicians") could result in inappropriate treatment. Patient authorizes Kingsberg Medical to receive copies of reports from medical laboratories, diagnostic testing services, Physicians and dispensing pharmacies relating to his/her treatment. In addition, Patient authorizes and instructs Kingsberg Medical, Physicians and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the information contained on the MHF, laboratory diagnostic tests, and other information submitted to Kingsberg Medical under this Agreement. Patient acknowledges that therapies and laboratory and diagnostic testing services obtained by Kingsberg Medical, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.

Patient acknowledges that Kingsberg Medical's employees and advisers are not licensed physicians and that Physicians obtained on my behalf by Kingsberg Medical are independent contractors, which will be compensated by Patient with funds provided to Kingsberg Medical. I further understand and agree that Kingsberg Medical and Physicians are rendering the medical care, services and treatment and that Kingsberg Medical is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence.

Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician, to immediately cease any medical treatment prescribed by Physician in the event of any adverse reaction or side effect arising from prescribed treatment and to immediately provide Kingsberg Medical and Physician with written notice of any such adverse reaction or side effect. I further acknowledge and agree that Kingsberg Medical is not liable for any negligent act or omission of the Physician.

Patient acknowledges that diagnosis and treatment may involve risk of injury, and that Kingsberg Medical and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the treatment being prescribed by Physician may or may not cause the effect being sought, and that such treatment is experimental and may not render any benefits, but may result in unknown, adverse results.

Patient is aware of the nature, risk and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone treatment. Patient acknowledges that human chorionic gonadotropin therapy involves the use of a medical drug approved for one purpose and being utilized for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone therapy for the purpose of authorizing Physician to administer such treatment to attempt to enhance Patient's physical condition and health. Patient further acknowledges that the methods of medical treatment offered by Kingsberg Medical and Physician are not accompanied by claims, guarantees, promises or warranties. In compliance with federal and state laws, there will be no refund given for any medication.

Patient is freely seeking medical consultation via the Internet and acknowledges and consents to Physician reviewing Patient's medical history without the opportunity to conduct an in-person physical examination. Patient solicits Kingsberg Medical for a specific prescription medication to treat an already-identified condition. Patient acknowledges that Physician may not be licensed to practice medicine in Patient's state or country of residence. Further, Patient agrees that Physician's consultations, diagnosis, and treatments will be deemed to have occurred in Florida, where Physician is licensed to practice medicine.

Patient represents that he or she is under the care of a primary care physician and the Physician, and he or she will not rely or substitute the advice of Physician should it conflict with the advice given by Patient's primary care physician. Before taking any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone therapy.

This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Palm Beach County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.

This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect. If any provision of the Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.

Patient's failure to disclose all relevant information regarding Patient's medical and physical condition, may result in acts or omissions by Kingsberg Medical or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Kingsberg Medical or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties herein or damages from the Indemnified Parties herein.

I have read the text above, and I agree to the terms and conditions disclosed herein.